United States

Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage
Elise Hogan, BS, Kiersten Woodyard, BS, Ermina Lee, BS, Douglas Dembinski, MD, Ryan Gobble, MD, FACS

Intro:
Gender affirming care is recognized by every major medical association in the US as medically necessary for the treatment of gender dysphoria1. However, a 2015 national survey of transgender individuals found that 25% of respondents were denied coverage for hormones and 55% were denied coverage for surgical care within that year2. Access to gender affirming care has been associated with improved health outcomes in the transgender population, but there is a paucity of literature characterizing wait time from initial surgical consult to gender-affirming mastectomy. The purpose of this study was to investigate insurer coverage practices for transgender patients seeking gender-affirming mastectomy at the University of Cincinnati Medical Center to better inform surgical providers and their patients.

Methods:
A retrospective review of patients presenting to our institution interested in gender-affirming mastectomies from July 2014 to January 2022 was conducted. Patients were sub-stratified into those with public insurance and private insurance providers. Patient demographic data was collected, including insurance type, race, ethnicity, age, BMI, and smoking status, with additional information such as time on hormone replacement therapy (HRT) and prior psychiatric involvement. Categorical variables were analyzed with t-tests, and continuous variables were examined via linear regression. 

Results:
90 patients were interested in gender-affirming mastectomies that presented to our institution; 67 were insured by public providers and 23 by private insurers. 51 patients went on to have surgery (56.67%); 38 patients with public insurance (74.51% of surgical patients; 56.72% of publicly insured) and 12 patients with private insurance (23.53% of surgical patients; 52.17% of privately insured). 77 of the original 90 new patient consults (85.56%) had previously documented psychiatric involvement; 49 of 51 surgical patients (96.08%) had documented psychiatric involvement. Surgical patients with public insurance were on HRT for an average of 21 months compared to 30 months for private insurance. Average time from initial consultation to surgery was significantly longer for public insurers, with an average of 280 days, compared to private insurers, with an average of 186 days. For both public and private insurance, there was no association between months on HRT and time to surgery. 

Conclusion: There is a delay in time to surgery associated with patients who have public insurance when compared to private insurance that is unassociated with time on hormone replacement therapy. Awareness of a patient’s insurance status allows providers to provide realistic surgical timelines more accurately for patients interested in gender affirming mastectomy. 





References
1. Baker, K. E. (2017). The Future of Transgender Coverage. The New England Journal of
Medicine, 376(19), 1801-1804. https://doi.org/10.1056/NEJMp1702427 
2. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., &amp; Anafi, M. (2016). The Report
of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender 
Equality. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf


AMA Research Challenge 2022

Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage
Elise Hogan, BS, Kiersten Woodyard, BS, Ermina Lee, BS, Douglas Dembinski, MD, Ryan Gobble, MD, FACS

Intro:
Gender affirming care is recognized by every major medical association in the US as medically necessary for the treatment of gender dysphoria1. However, a 2015 national survey of transgender individuals found that 25% of respondents were denied coverage for hormones and 55% were denied coverage for surgical care within that year2. Access to gender affirming care has been associated with improved health outcomes in the transgender population, but there is a paucity of literature characterizing wait time from initial surgical consult to gender-affirming mastectomy. The purpose of this study was to investigate insurer coverage practices for transgender patients seeking gender-affirming mastectomy at the University of Cincinnati Medical Center to better inform surgical providers and their patients.

Methods:
A retrospective review of patients presenting to our institution interested in gender-affirming mastectomies from July 2014 to January 2022 was conducted. Patients were sub-stratified into those with public insurance and private insurance providers. Patient demographic data was collected, including insurance type, race, ethnicity, age, BMI, and smoking status, with additional information such as time on hormone replacement therapy (HRT) and prior psychiatric involvement. Categorical variables were analyzed with t-tests, and continuous variables were examined via linear regression. 

Results:
90 patients were interested in gender-affirming mastectomies that presented to our institution; 67 were insured by public providers and 23 by private insurers. 51 patients went on to have surgery (56.67%); 38 patients with public insurance (74.51% of surgical patients; 56.72% of publicly insured) and 12 patients with private insurance (23.53% of surgical patients; 52.17% of privately insured). 77 of the original 90 new patient consults (85.56%) had previously documented psychiatric involvement; 49 of 51 surgical patients (96.08%) had documented psychiatric involvement. Surgical patients with public insurance were on HRT for an average of 21 months compared to 30 months for private insurance. Average time from initial consultation to surgery was significantly longer for public insurers, with an average of 280 days, compared to private insurers, with an average of 186 days. For both public and private insurance, there was no association between months on HRT and time to surgery. 

Conclusion: There is a delay in time to surgery associated with patients who have public insurance when compared to private insurance that is unassociated with time on hormone replacement therapy. Awareness of a patient’s insurance status allows providers to provide realistic surgical timelines more accurately for patients interested in gender affirming mastectomy. 





References
1. Baker, K. E. (2017). The Future of Transgender Coverage. The New England Journal of
Medicine, 376(19), 1801-1804. https://doi.org/10.1056/NEJMp1702427 
2. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report
of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender 
Equality. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf


poster

Background: One of surgical indications for orbital fracture repair is enophthalmos. Predicting late enophthalmos during initial work-up is a clinical challenge due to periorbital edema, and objective guidelines to direct surgical management in these cases remain ambiguous. We systematically reviewed the existing data on objectively predicting late enophthalmos using CT findings during initial trauma work-up.

Methods: Embase and PubMed were used as databases to identify articles of interest. Included articles were English-language prospective and retrospective studies that utilized CT findings to predict enophthalmos in asymptomatic patients. The Quality in Prognosis Studies (QUIPS) tool was used to identify potential risks of bias. A random effects model meta-analysis of orbital volume change was completed. A regression analysis of 224 data points from 8 orbital volume change studies was performed to determine a pooled threshold for 2mm (clinically significant) enophthalmos.

Results: Initial search delivered 2236 abstracts. 96 articles were selected for full-text review, and 36 met inclusion criteria. 30 retrospective studies evaluated a total of 2851 patients and 6 prospective studies evaluated 211 patients. All 36 articles had predominantly low risk of bias in six assessed domains. 5 articles on fracture location in 969 patients showed that inferior, medial, and medial-inferior orbital fractures were predictive of enophthalmos. 6 articles on inferior rectus muscle displacement in 323 patients showed that CT-notable displacement of IRM, height-to-width ratio more than 1.0, and increased IRM swelling by 60% served as predictors. 12 articles on fracture area in 861 patients offered values ranging from 1.5 go 3.38cm2. 21 study on orbital volume change in 835 patients offered values ranging from 0.688 to 4.26cm3. Five of those articles offered orbital volume ratios of 105.0% to 114.0%. Meta-analysis showed an effect size of 1.5, confirming the validity of orbital volume change as enophthalmos predictor (p<0.001, CI 0.952-2.067). Regression analysis revealed that 3.33cm3 of orbital volume change was a predictor of 2mm enophthalmos. Egger regression (p=0.095) and funnel plot revealed low risk of publication bias.

Conclusions: Simple measurements accessible on two-dimensional CT scans can be used as predictive values for late enophthalmos. Orbital volume change is the most researched predictor.

What CT Findings are Predictive of Post-Traumatic Enophthalmos in Orbital Fractures?

Background:
Schizophrenia can be understood to exist on a spectrum; from non-clinical individuals with higher levels of schizotypal personality traits to patients with schizophrenia. Studying schizotypy in non-clinical populations can be extremely informative, given that schizotypy is positively correlated with an increased liability for the eventual development of a schizophrenia spectrum disorder. By studying schizotypy, researchers may be able to detect biomarkers for early detection of psychosis and identify brain regions that may be targets for treatment. 
Our lab previously found that neural adaptation to reward range is impaired in both healthy individuals with stronger schizotypal personality traits and in patients with schizophrenia. However, it remained unclear whether these deficits are limited to the reward domain, or extend to other domains as well. To this end, I developed a novel perceptual adaptation task aimed at detecting differences in adaptive coding in the visual perception domain. 

Methods:
We present morphed images to participants who decide whether a presented image is a face or a house. The morphs are shown in wide range blocks (2.50% - 97.5% face), and in narrow range blocks (27.5% - 72.5% face), and we expect the performance of healthy participants to adapt to the range of morphs, and we expect the performance to be negatively correlated with schizotypy.

Results:
We find that participants behaviorally adapt to the range, such that for similar images, performance is more accurate in the narrow range blocks compared to the wide range blocks. However, we find no link between perceptual range adaptation and schizotypal personality traits.

Conclusion:
Our findings suggest that the inability of those on the schizophrenia spectrum to adapt to the range seen in reward tasks does not generalize to the visual domain. These results may indicate that the deficits seen are specific to the dopamine reward pathways of the brain, highlighting a potential target for future studies to investigate interventions (i.e. behavioral interventions or brain stimulation) in an effort to decrease progression along the schizophrenia spectrum. 


Are there Adaptive Coding Deficits in Object Categorization across the Schizotypy Spectrum?

Abstract Title: 

Correlation between ECT quality measures & likelihood to transition from acute to continuation ECT and then to maintenance ECT 

Background 

Electroconvulsive therapy (ECT) uses an electric current to induce a generalized seizure under general anesthesia to treat psychiatric conditions including major depressive disorder, bipolar disorder, schizophrenia, schizoaffective disorder, and catatonia. In the current literature, there is a lack of consensus regarding which quality measures can reliably predict clinical outcomes. Some proposed markers for effective ECT include seizure duration greater than 25 seconds, high postictal suppression (i.e. extent to which EEG activity diminishes after the seizure ends), and a larger magnitude of difference between baseline and peak heart rates during the procedure. 

Methods 

Our study is a retrospective medical record review of all patients who started ECT at CHI Health Immanuel Hospital between July 2016 and July 2019. We gathered data on patient demographics, psychiatric diagnoses, ECT parameters (electrode placement, pulse width, energy level) and ECT quality measures (seizure duration, postictal suppression, and heart rate response). 

Treatment sessions were categorized into three groups to measure progression through ECT treatment: acute, continuation, and maintenance. Acute treatment involves receiving ECT 2-3 times weekly for at least 4 weeks. Continuation treatment receives ECT once every 1-4 weeks for 6 months after the last acute treatment. Maintenance ECT undergoes treatment once every 1-4 weeks after completing continuation treatment. Independent variables are ECT quality measures at each treatment. The primary outcome is time to transition from acute to continuation to maintenance. 

Results 

2,506 ECT encounters were observed for 114 patients. Data were analyzed using the proportional odds assumption. After adjusting for postictal suppression index (PSI) and HR change, a 10-second longer seizure duration was associated with 10% higher odds of progressing to the next ECT category (p <.001). After adjusting for seizure duration and HR change, every 10-unit increase in PSI was associated with 7% higher odds of progressing to the next ECT category (p = 0.009). After adjusting for seizure duration and PSI, a 10 bpm increase in HR change was associated with 4% higher odds of being in the next higher ECT category (p = 0.174). 

Conclusion 

Our study found that longer seizure duration and higher PSI were associated with higher odds of progressing through ECT treatment.

Correlation between ECT quality measures & likelihood to transition from acute to maintenance ECT

Factors in Psychiatric Recidivism

Background
Mental illness presents an evolutionary paradox – it is common, heritable, and deleterious to fitness. Under these circumstances, natural selection should deplete genetic variation underlying mental illness, decreasing its prevalence. Various evolutionary mechanisms may resolve this paradox, yet empirical investigations of these mechanisms are lacking. Prior studies have measured selection in one generation. However, if the relationship between the symptoms of mental illness and fitness changes between generations then fluctuating selection may be maintaining mental illness in populations. Here, we examine the relationship between depression
and fitness to provide an empirical test of this mechanism.
Methods
We obtained severity of depression (PHQ-9 scores) and fitness components (lifetime number of sexual partners, pregnancies, and births) for a nationally representative U.S. cohort of 10030 women ages 20-69 born between 1938-1994 in the National Health and Nutrition Examination Survey. We compared mean PHQ-9 scores and fitness components among four generational cohorts (Silent Generation, Baby Boomers, Generation X, Millennials). Using generalized linear
models, we examined the relationship between PHQ-9 scores and fitness components in each generation separately with age, BMI, education, ethnicity, and income as covariates. We corrected p-values using false discovery rate.
Results
Mean PHQ-9 score and fitness components differed among generations (all p<0.0001). In each generation, women reporting higher PHQ-9 had more lifetime sexual partners (all p<0.001). Women reporting higher PHQ-9 also had more lifetime pregnancies (all p<0.01) except in the Silent Generation (p=0.95). The relationship between PHQ-9 and lifetime births was significant only in the Baby Boomer generation (p=0.02).
Conclusion
Our results demonstrate the relationship between depression and fitness changes between generations, supporting the hypothesis that fluctuating selection contributes to the persistence of depression in populations. Surprisingly, the correlation between severity of depression and number of sexual partners remained consistently positive. This finding suggests a conflict between sexual and natural selection, possibly weakening selection against depression. Our data is limited by the assessment of depression at a single timepoint and in one biological sex. Future
work should focus on biological and cultural mechanisms underlying the observed patterns. Investigating which mechanisms mediate relationships between depression and fitness may illuminate novel therapeutic targets.

Fitness consequences of depression fluctuate across the 20th century in a large cohort of women

Background
Invisible wounds of war such as posttraumatic stress (PTS) account for a huge burden of disease for US military veterans. Studies have shown that 13.5% of deployed and non-deployed Iraq and Afghanistan veterans screened positive for PTS while this number is estimated to be as high as 25% among Vietnam veterans. Heart Rate Variability (HRV) training has shown promise in aiding this population. HRV, which is a proxy measurement of nervous system health, is an important indicator of well-being, fitness, and stress resilience. While there have been many studies that have illustrated the benefits of HRV training for those coping with emotional distress, there is a lack of robust research exploring the benefits of training in group sessions versus individual sessions.

Methods
Enrollment will consist of 60 US military veterans, aged 20-75, who are proficient English speakers and have at least one invisible wound of war including PTS. HRV trends with be monitored using wearable devices. HRV data will be individually correlated to each participant’s baseline HRV prior to training. Training will occur either one-on-one with a certified HRV coach, or in a group setting led by the same HRV coach. The following outcome measures will be collected before and after coaching: Stress and Well-Being Assessment (SWBA), Pittsburg Sleep Quality Index (PSQI), Posttraumatic Stress Disorder Checklist, NIH PROMIS Global Health Short Form, and the NIH NeuroQOL Cognitive Function Index.

Results
We anticipate our group-trained cohort will have a greater degree of improvement from baseline, as reflected in the standardized index scores, when compared to our individually trained cohort. This idea is supported by prior studies illustrating the synergistic improvements in HRV seen in group settings which has been referred to as social coherence.

Conclusion
Providing veterans suffering from invisible wounds of war with tools to manage their overall stress is of great benefit to society. We hope that the results of this study can be used to guide future implementation of this non-invasive, easily accessible, evidence-based, and cost-effective intervention in groups that may be suffering from invisible wounds such as healthcare professionals. 


Heart Rate Variability in US Military Veterans: The Power of Teams

Music’s ability to evoke and communicate emotion is widely recognized, but the ways in which music can be used to change, dampen, maintain, or enhance various mood states warrants further investigation. While existing research has elucidated several strategies for using music to regulate emotion, the relationship between mood regulation strategy and the affective experience of music listening has not been explored. Understanding how methods of mood regulation relate to the affective dimensions of valence (positive-negative) and arousal (activating-relaxing) can help maximize music’s potential to promote emotional wellbeing. In this study, compositional strategies such as tempo, mode (major or minor), and instrumentation were used to produce four songs that targeted four dimensions of emotion: happy, calm, sad, and tense. A Qualtrics survey was used to collect valence and arousal ratings for each song (n = 142 respondents). The survey also included the Brief Music in Mood Regulation Scale (B-MMR), a validated measure that assesses seven strategies for using music to regulate mood: Entertainment, Revival, Strong Sensation, Diversion, Discharge, Mental Work, and Solace. Chi-squared analysis revealed that each song accurately conveyed its targeted emotion; however, paired t-test analysis of core affect ratings showed that the sad and tense songs had a more positive than negative valence. Correlation analysis and Fisher transformation unveiled relationships between positive valence and the regulation strategies of Revival, Strong Sensation, Diversion, and Mental Work; negative valence was related to emotional Discharge. Arousal was not related to mood regulation strategy. These results reveal that a song’s emotional valence can influence its compatibility with certain strategies of mood regulation. Applying these findings to everyday music listening can influence song selection based on the intended mood regulation strategy, thereby maximizing music’s effectiveness for regulating mood.

Keywords: music, affect, valence, arousal, mood regulation

Music and Mood: The Relationship Between Affective Experience and Mood Regulation in Music Listening

Background Selective serotonin reuptake inhibitors (SSRI) are the gold standard treatment for major depressive disorder (MDD). However, the use of phosphodiesterase (PDE) inhibitors in treatment of MDD remains unclear. The aim of our study was to compare the effect of PDE inhibitor + SSRI combination therapy to SSRI monotherapy for the treatment of MDD.
Methods We performed a comprehensive literature search using PubMed, EMBASE, and Web of Science databases from inception to 07/08/2022, for studies that assess the impact of PDE inhibitor therapy on MDD patients. The primary outcome of our study was treatment response rate (defined as ≥50% reduction in the Hamilton Rating Scale for Depression score) at the end of study time. Secondary outcomes included specific side effect rates. Pooled odds ratio (OR) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A P-value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I2 index (I2 values >50% implied the presence of significant heterogeneity).
Results A total of four randomized control trials (RCTs), including 270 patients with MDD (mean age: 34.9±8.4 years, 135 patients received PDE inhibitor + SSRI combination therapy and 135 received SSRI monotherapy), were included in the analysis. The follow up period ranged from 6 to 12 weeks. The PDE inhibitor group was associated with a significantly higher treatment response rate (OR:4.77; 95% CI:2.05-11.12; P = 0.0003). Additionally, there was no significant difference in side effect rates between the two treatment modalities.
Conclusion Our study supports the use of PDE inhibitor + SSRI combination therapy in patients with MDD, since it is associated with a significantly higher treatment response rate compared to patients receiving SSRI monotherapy (90.4% vs 64.4%, respectively). Further large-scale RCTs with long-term follow-up are necessary to validate our findings. Ultimately, use of PDE inhibitors in MDD patients should be considered on a case-by-case basis to maximize patient benefits.

Phosphodiesterase Inhibitor and SSRI Combination Therapy Versus SSRI Monotherapy for the Treatment of Major Depressive Disorder: a Systematic Review and Meta-Analysis

Background: Suicide continues to be one of America’s largest public health concerns. In response to the growing need for screening hospitalized patients for suicidal behavior and ideation, a Northeastern United States Hospital (NEUSH), in conjunction with Columbia University, implemented a screening version of the Columbia Suicide Severity Rating Scale (C-SSRS). The original project, published in 2020, evaluated the feasibility and initial results of using this screening tool in a NEUSH on the inpatient acute care floors. Now, this study aims to update the scientific community on the progression and effectiveness of this C-SSRS screening tool at the same NEUSH with a larger sample size.
Methods: A total of 261,681 patients aged 18 and over were screened by trained nurses during the time period of July 1st, 2011, to June 30, 2021. Data was collected using the Electronic Medical Record Systems that the hospital was using during that time frame (Clin Doc© and Epic©). 
Results: From the 261,681 adult patients who were screened with the C-SSRS Screener, 1,375 (44.6%) scored a Level 3, another 198 (6.4%) scored a Level 4, and 1,509 (49.0%) scored a Level 5. Overall, 1.18% (3,082/261,681) of admissions had a psychiatric consult recommended due to the level indicated by the C-SSRS and a total of 2730 consultations were performed by the psychiatry department as a result of a Level 3 or higher on the C-SSRS screening. Over 99% of the consults performed from C-SSRS score of Level 3 or higher were deemed appropriate. Regarding disposition of patients who scored a Level 3, 4, or 5 on C-SSRS screening, 976 (31.7%) were referred to either start or continue outpatient mental health care, another 689 (22.4%) were discharged to home, and 623 (20.2%) were discharged to the inpatient psychiatric facility of the NEUSH.
Conclusion: These findings suggest that the C-SSRS Screener continues to be a low burden effective screening tool that can identify suicidal ideation and behavior in high-risk patients admitted to the hospital. Any hospital needing a method to screen for suicidal ideation and behavior should consider the C-SSRS Screener as a possible solution to their needs. 


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